Healthcare Provider Details

I. General information

NPI: 1417072356
Provider Name (Legal Business Name): NICOLE REYNOLDS SMALL MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 01/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 S 3RD ST
MOUNT VERNON WA
98273-4301
US

IV. Provider business mailing address

1701 30TH ST
BELLINGHAM WA
98225-7603
US

V. Phone/Fax

Practice location:
  • Phone: 360-419-3612
  • Fax: 360-419-3605
Mailing address:
  • Phone: 310-210-8662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW18384
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberPPSC #060034254
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberRC00058160
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number443673R
License Number StateWA
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW 60064972
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: